Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. I hope the pages can help you learn about caring for foot injuries, or help you with your own injury.
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Showing posts with label Tarsal Tunnel Syndrome. Show all posts
Showing posts with label Tarsal Tunnel Syndrome. Show all posts
It's been a while since I have been to see you. I hope you are well.
When I was in your office last I was dealing with tarsal tunnel syndrome, and I solved it with repeated acupuncture. However, the acupuncture does not seem to be doing the trick anymore, and it has become too painful for me to run. Shall I come back to visit you or do you know of a specialist that might be able to help me?
Thanks so much for your help.
Dr. Blake's response:
I will be happy to re-evaluate. I am including a blog post I wrote to see if anything can be addressed.
The following is a short piece from my book "Secrets to Keep Moving: A Guide from a Podiatrist"
1. Introduction to Nerve Pain Treatment
First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves you should be addressing 4 areas---mechanics (what stresses the nerve and what protects the nerve), anti-inflammatory (in general, contrast bathing or warm water soaking is better than ice, along with oral & topical anti-inflammatory meds), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc).
Therefore, the standards of care I use for nerve pain in the foot and ankle involve the following:
1. Mechanics
2. Anti-Inflammatory
3. Nerve Desensitization
4. Diagnostics
It is the 4 areas that form the basics of each visit decision making. The KISS (keep it simple stupid) principle does apply based on the level of pain and disability being produced.
Mechanics
The 3 aspects of mechanics for nerve pain on the foot/ankle (and other parts of the lower extremity) are:
1. Recognizing if motions or positions that the patient places themselves in can
stress the sciatic nerve and its branches.
2. Creating protected weight bearing environment so that every step does not create
pain. This is done with inserts, braces, pads, shoe gear, etc.
3. Protecting a sore spot when shoe pressure causes pain with pads, sleeves,
skipping laces, etc.
Anti-Inflammatory:
Nerve pain may be neuropathic (produced by the nerve itself), inflammatory (produced by inflammation around the nerve), or a combination. When treating nerves, various anti-inflammatory measures should be tried to see if there is a response. Ice, one of the mainstays of anti-inflammation can be very irritative to nerves and may have to be limited to 5 minutes. Massage can also have the same helpful or irritating effect. So, anti-inflammatory treatments of nerves can be a little more tricky than treating tendinitis. Contrast bathing, warm socks, oral meds, topical patches may be helpful.
Nerve Desensitization:
Nerve pain can spiral out of control easily, so doing treatment to desensitize the nerve from the start can be very helpful. I typically start with an OTC medicine called Neuro-Eze (product online) and Neural Flossing or Gliding (both done 3 times daily). Oral medicines are started only in the evening, and started at low doses, like Lyrica, Neurontin etc. But, many of my patients get wonderful help with Acupuncture, skin rolling (common for fibromyalgia), or Compounding topical medications.
Diagnostics:
From the first visit, I continue to ask do I need more information. Low Back Evaluations, MRIs, lab values, Nerve ConductionsTests & Diagnostic Injections can all play a vital role.
I am wondering how to know if the pain in my foot/ankle/lower leg is coming from the FHL, FDL, or Tibialis Posterior? They all seem to have the same location and trigger points from the muscle are also close together. I would like to do self-massage to release whatever is trapped/tight if possible.
Dr Blake's comment: These are the 3 tendons that run together in the tarsal tunnel.
Some history:
Two and half years ago, I injured my FHL tendon where it meets my sesamoid (imaging showed inflammation and swelling at 1st metatarsal, fracture of sesamoids ruled out) on my right foot. I developed nerve pain as a result (in right foot and leg, and mirror nerve pain in left foot and leg), as well as piriformis syndrome in my right glute from the gait changes. Tendon eventually healed, but different kinds of nerve pain/patterns and piriformis muscle pain remained, sometimes mild sometimes more severe. Additional imaging ruled out lower back/SIJ issues.
Two months ago, I developed an intense tension in my right foot, very close to my Achilles tendon, between my Achilles tendon and ankle bone on the inside of the leg, when walking. Tension would feel like somebody was pulling my heel back whenever I tried to take a step forward, as if one of the tendons/ligaments was too short and bouncing back each time. Pain could not be reproduced on pressing the area of the pain, just when stepping forward. Pain only appeared when I put on my shoes and took a step, when at home in flip-flops I could walk pain free. The pain came and went for about 10 days, then disappeared. Dr Blake's comment: This is classic tarsal tunnel (nerve) symptomatology, not tendon.
A week ago I started feeling pain in my right foot, starting from the bottom just in front of the heel (between heel and arch) and shooting upwards towards the back of my ankle bone on the inside of my leg. Not a nerve pain feeling, but a tension again, less severe than two months ago, different spot (but nearby), and sometimes starts tingling sligthly when I press on it.
Dr Blake's comment: It is called neural tension, and definitely neurological.
Tried rolling foot on tennis ball at point of pain and felt tingling on bottom of foot towards big toe (similar to pain from FHL injury 2.5 years ago but much less intense). Did not continue rolling on ball. Being familiar with trigger points, I press my lower leg up from ankle (on inside of leg) to calf and get some referred pain into my foot between the heel and arch. Pain is felt when swimming, walking, and stretching body when waking up (tension/soreness) and when not moving (dull throbbing ache).
Dr Blake's comment: It is half neurological, and half tendon, the way you describe. When the 3 tendons are individually stressed, how do you feel? Rich
Any ideas of which tendon this could be and suggestions of how to release whatever is pulling on the tendon would be much appreciated! I would rather not go to doctors and physiotherapists all over again, but would not want to leave this if it might get worse. I got used to the residual/chronic nerve pain and piriformis muscle pain but would not want to start shifting gait again.
Dr Blake's comment: If you were in my office, and I tested the 3 tendons without problem, I would put you on a tarsal tunnel protocol of neuro flossing, neurological-eze gel top massage, no stretching, active ankle range of motion, warm soaks 20 minutes twice daily, orthotics or sole wedges if you pronate, and consider lyrica for evening at least. Rich
I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM
I found a pair of orthotics that were custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.
My question is would you be able to to make a new pair of orthotics for my back pain since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.
Thanks-
Dr Blake's response:
Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control.
When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also.
The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done.
There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich
Accessory Navicular Problems: Further info from the initial blog post
Dr. Blake,
I am a 31-year old professional who currently works in an office in Massachusetts. Last year, however, I spent 9 months in Spain teaching English. I had no car and found myself doing lots of walking. I also gained about 15 pounds in the first couple of months there. I noticed after three months of walking in ballet flat style shoes a burning sensation in my right ankle. Long story short, here we are a year and a half later and I still have the pain. I weigh about 125 and am 5'2".
Dr Blake's comment: Tentative diagnosis is Tarsal Tunnel Syndrome. This is neuropathic pain, and needs to be treated with a nerve emphasis, some mechanical changes, and some anti-inflammatory measures.
I have seen a total of four doctors so far. I have done PT, tried custom orthotics (which I lost during my move back), tried a walking boot for 6 weeks, been on a couple strong NSAIDs, modified my activities, and tried ice and heat therapy at home on a sporadic basis.
Dr Blake's comment: This problem is helped with the mechanical support of the orthotic devices, especially if there is some varus wedge at the heel. Also, nerves love heat not ice, motion not lack of motion, no massage, and gentle stretching (like neural gliding).
The orthotics caused more foot pain in other areas, so I am not sure they were made properly for my condition. The PT was done in Spain a year ago and consisted of 45 minutes of heat therapy, electric wave therapy, and massage every day for three weeks.
Six weeks in the boot this past winter was creating problems in my left knee and hip. They never gave me a leveler for the other side, but I did wear a high shoe which seemed okay.
Please help with your opinion! My current doctor who is an orthopedic surgeon and prescribed the boot is of the persuasion that PT and orthotics will not help the edema he sees on the MRI in my bones. I personally want to try a new PT routine and new orthotics before I resort to surgery, but that means I will have to move on to a new doctor yet again. Two doctors were in Spain and the other was here in the U.S. (podiatrist with a horrible bedside manner who said paying $400 for orthotics from his office was the only option).
I am so frustrated and feel like I have tried everything but I also think the timing and quality of the things I have tried could be reassessed and tried again. What do you think?
I don't want surgery if possible. It is my right foot and it will make me unable to drive.
Dr Blake's comment: Without a history of a fall or collision causing major injury, the need for surgery is typically small. Yes, starting again sounds the best. The bone edema could be residual for a stress fracture that has healed or is still healing, and the inflammation from the bone injury putting pressure on the nerves leading to the burning. Burning is classic nerve pain. You need to create your pain free environment however while you search out a new doctor. Typically sports medicine doctors, not necessarily podiatrists or orthopedists, are the best. If 6 months has passed from the first MRI, get another to assess the amount of healing. You may not feel any better until the bone edema is all healed. It is a reflection of bone trauma. Go back into the boot part of the day if you can not find another environment to keep the foot happy. See if warm water soaking works better than contrast bathes. If your skin can tolerate some massage, order NeuroEze online and massage 3 times per day, at least above and below the sore areas. Also do neural gliding 3 times per day, as long as it is comfortable. If warmth or contrast does not help, stay with ice packs. You can experiment with placing the ice pack over the area, or above it. Send me other info on what you have found works and does not work. Are you better in heels vs flats, barefoot vs shoes, etc? How long can you walk without limping? Send a photo of your foot with your finger pointing to the exact area. Hope this starts the forward progress. What exact diagnoses have you been given? Rich
Hi Dr. Blake,
Thank you so much for responding. I will do my best to answer your questions.
I have an accessory navicular in both feet (see photo of right foot with me pointing to general area of pain). I only realized they existed recently, because they never caused me any pain before, and I only present symptoms in the right foot. The pain changes places; sometimes it is under the arch, and other times there is a shooting pain up the post tibial tendon. Some days it feels like a rubber band about to snap with too much pressure, and other days it's that burning I described. I also have flat feet. Dr Blake's comment: That definitely sounds more like an accessory navicular problem. Since it involves the posterior tibial tendon in the tarsal tunnel, you can get nerve pain or nerve symptoms being generated.
It seems like switching shoes often helps. Barefoot is bad. I have spent more money on shoes in the past year than in my entire life! Dr. Scholl's inserts, MBT rocker bottom shoes (horrible for my condition), Clarks, sneakers, really expensive clogs, etc. The clogs (with a raised heel) are my favorite. However, I refuse to wear them in the summer as I still have some sense of fashion to maintain. I just bought some comfortable Clarks to get me through the summer that look like ballet flats but have a much better sole and support, with a wide toe. I'm also in love with Okabashi flip flops, and wear them around the house as much as possible.
Dr Blake's comment: If you can get comfortable, but stable orthotic devices, the design can be used in your sandals with a removable insole.
The MRI was done in January 2015 and we are now in May. My condition has not changed symptomatically since December 2013. My orthopedist believes that physical therapy will inflame the edema more, or be useless. He is also not a fan of orthotics, which I tend to agree with, because from what I've read online, they don't make your feet work hard enough and allow them to lazily conform to a mold. Some doctors believe they create dependency. What is your view on this?
Dr Blake's comment: I love orthotics for this problem. I believe you only need to do 2-3 minutes a day of strengthening to make up for any weakness from the bracing effect. And strengthening the posterior tibial tendon should be part of your program. You must understand, since you are still trying to get into a pain free environment for most activities, you are still technically in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, so any assistive aid is very appropriate now (especially when some are suggesting surgery).
So you think I should try using the boot again even though it didn't cure the condition in 6 weeks, just for comfort, while I search for a sports medicine doctor? The boot does cause problems in the left hip and knee if I wear it too long, but I will certainly do anything to get better! I will also mention that I am developing a bunionette on the right foot from compensating, as well as from wearing winter boots with a tapered toe. Not too happy about this!
Dr Blake's comment: See the video on Tailor's Bunion care.
I am currently taking Meloxicam and it doesn't seem to be helping after a month. I was on Indomethacin for a few weeks, and while I believe it did help reduce inflammation temporarily, the side effects were awful. You are correct in stating the foot likes heat better than ice.
Dr Blake's comment: At this stage you have both inflammatory pain and nerve pain. And they can trade off on a daily or weekly basis what gives you the current symptoms. Try to see if you can distinguish the various types of pain, and what treatments help them.
My life has changed completely and I cannot play tennis, do Zumba classes, or walk long distances anymore. It has affected my social life and career as I must ask co-workers, family and friends to coordinate activity around my pain. Sometimes I push myself when I'm alone because I need to get things done (cleaning, vacuuming, etc). but I suffer the following two days recovering.
Dr Blake's comment: This is why I would err on getting and learning all forms of immobilization: various taping, different orthotic designs, Aircast PTTD brace, removable boots, AFOs, shoes, and power lacing. Read the posts on posterior tibial tendon dysfunction to see all these avenues like the one below.
The reason I have hope for recovery is that I have had a couple sporadic days with absolutely no pain. I did not change anything activity-wise, so I have no idea what alleviated the symptoms. I hope I am being reasonable by avoiding surgery. I am very anxious about it, but I also don't want to avoid it forever if it's really the best option. It seems that the body can heal itself in many cases given the right conditions, and want to exhaust all options before going under the knife, being out of work, collecting disability, etc. I am a very active person and while I have rested the foot a great deal, I won't pretend it's been easy to slow down.
I'd like to lose 10 lbs. because I think being a little lighter will alleviate some pressure, but I am not even overweight and don't want to have to maintain a low weight my entire life just for this reason (I.e., what if I get pregnant someday)? I think the weight is a contributing factor, not a root cause. I am having a hard time losing weight with the condition, ironically.
Thank you again for your time, Dr. Blake. I sincerely appreciate it!
Dr Blake's comment: Good luck. Here is my typical checklist for accessory navicular issues (with tendinitis and tarsal tunnel symptoms just part of the overal syndrome).
The top 10 treatments for accessory navicular syndrome:
1. An MRI is very important to discover what the source of pain actually is: stress fracture, joint inflammation, or tendinitis. There is a joint between the navicular and its accessory bone.
2. Use Kinesio Taping or supportthefoot.com tape or classic low dye taping techniques intially 24/7 and then for extended activities.
3. Ice pack the sore area 10-15 minutes 3 times daily.
4. Go into a removable boot (such as an Anklizer) for 2-3 months if needed to calm the foot down.
5. Strengthen the posterior tibial tendon starting initially with active range of motion like ankle circles.
6. Check out the Aircast Airlift PTTD brace to see if it is helpful for you and can get you out of the boot faster.
7. Custom foot orthotics are a must for a 2 year period. They must produce a good force against the navicular, but it may take time finding the right orthotic guy/gal.
8. You can use Sole OTC orthotic devices with medial longitudinal Hapads initially until a good protective orthotic device is made.
9. Create a pain free environment as soon as possible (level 0-2).
10. If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.
This is an email from a patient with left foot tarsal tunnel syndrome or some variant. I have worked with her for many years with ups and downs. Here is her latest email. She has been so limited for the last 9-10 years!!
Dear Rich,
I hope this email finds you well on this gorgeous October Sunday.
I want to write you an update as we haven't been in touch for some months. IT'S GREAT NEWS!!! I truly am progressing with my healing! Oh, I am thrilled to be out of constant pain.
Here are some bullet points for you:
*Since June, I've been doing weekly sessions with the orthopedic acupuncturist who I told you about. Going from 2x/month to 1x/week has made a significant, enormous, an unbelievable positive impact on my pain level. Whereas my pain was about an 8-9 in May, it's at approx. a 3-4 these days. AND, as a result of seeing him, I've increased my mobility and haven't had a debilitating flare-up for about 5 months.
*The Somatic Experiencing/Heller work sessions that I've been receiving 2x/month for the past 10 months has made a substantial impact on working through compensatory issues related to my foot injury and also is slowly making inroads into areas of my pelvis that hold habitual tension, which seems linked to the nerve pain (possibly due to my gait). This work focuses on the layers of tissue and supports the ANS to come back on line in healing ways.
*Since August, I've been receiving 2 hr Ayurveda lymphatic drainage sessions 1x/month. I'll be going for my third session in about a weeks time. After plugging into the benefits of acupuncture and hands-on SE I had this intuitive and intellectual hunch that I needed to clear stagnant lymph in ways that I hadn't yet. Of course the color of my foot indicated stagnation and I was clear that I needed to tend to it in more significant ways in order to progress. I asked around for a referral and now see this extremely eccentric woman. This, Rich, is the third leg of the stool! I am now doing salt scrubs daily and focus on clearing lymph throughout my body. Previously, I had thought that some of my old injuries, ie. metal pipe to the temporal lobe on my right side behind my ear and a hip injury, manifested as either bone out of place or tissue adhesion. Actually, it was stagnant lymph! My neck, at the occipital ridge on the right side, is freeing up and the hard grain-like/stone-like crystals of stagnated lymph are softening as a result of daily work and I truly feel invigorated! The color of my foot is changing and looks like a "normal foot" besides when my body gets really hot or when in the shower (same thing, actually). If the nerve corresponded to the color of my foot, then my pain level would be about a 0-1.
*My mobility continues to improve, however extremely slowly. I still can't walk on pavement for more than 4 blocks, standing remains challenging and activating, and I have to limit exercise to 30-35 minutes unless I sit and rest for a half hour to hour between. About 4-5 months ago I shifted my workouts from only doing 850-1000 stairs 2x/week as it kicked in plantar fasciatis on the right foot. I wasn't able to dance on the floor or even do sit-ups because the nerve in the inside area of the left ankle (tibial nerve?) simply couldn't handle any movement sideways, at all. I tried to do the "nerve flossing" once or twice and it exacerbated the nerve to about an 8 out of 10. I don't think that my nerve is ready for that.
*I found myself frustrated, yet not for long! I decided to try to stand up, in order to stabilize the nerve from moving laterally, and to dance while taking the weight off of my foot, of course because the nerve can't sustain pressure and weight. So, I now dance in my bathroom!!!! I tell you, Rich, I truly should do a YouTube video for people with similar issues. I break a sweat, isolate stomach muscles by doing stand-ups (sit-ups), and strengthen leg and arm muscles by using the sink, vanity, door jam, door knobs... so many options. I am so thrilled, so happy to move, to sweat, to build muscle back, to lose weight, and to feel like an athlete again! It's wild how much muscle I've lost over the course of the past 2 years as a result of not moving much at all... Luckily, I have core strength from being an athlete and a tomboy since I was a young girl. Muscle is returning and..... oh, to dance!!!! And, there are times when I stand and dance without taking the weight off of my foot and I'm doing great. It's perhaps for a 1-2 minutes max, yet that's so fabulous isn't it??!!
* I tape my foot every time I exercise or when I walk for more than 10-15 minutes. I use the thin tape and the wide tape... in the original way you showed me. The thin piece is applied along the sides of my foot first and then the wide tape is pulled up at the arch and down to the ridge of the heel. It helps alot by supporting my weight.
*I'll be seeing a neurologist at UCSF tomorrow afternoon (10/13). This will be the first time that I've consulted with a muscular/skeletal focused neurologist. I want to cover my bases and to see if he has any insights that I have yet to consider.
*In a couple of months, I would like to consider slowly reducing my Gabapentin from 1200 mg/day to 900 mg/day - 100 mg at a time, to see if I'm able to maintain my current progress. Do you have any thoughts about this? I know that nerve grows about 1/16inch/day so perhaps I should wait... or I should continue to work through the impingement to the nerve and then wait for it to recover.... Thoughts?
I know that there's more to share, however this is all that's coming to me at this time.
How are you???
I'm so thrilled to write about my progress. You've been in my thoughts a great deal. My hope is that this will serve some of your clients.... Rich, the lymphatic self-massage is so important.
I have been studying your blog for a few weeks now and enjoying your expertise and caring manner. I wish you could be my Dr, I am looking for advice on how to direct my podiatrist appointment in 9 days. I will try to make this to the point. 10 yrs ago I stepped down on a rock while saving my son from an active dog and got a stress fracture on my sesamoid.
Wore a boot and orthotics made by podiatrist. In the last 6 months I began having knee/calf pain and my sesamoid toe - the big one - was acting up. Podiatrist took xray and didn't see fracture and added a dancer pad to my orthotics. The sesamoid started feeling better, but I still had the mild calf/knee pain and the ball and heel of my foot hurt when I walked barefoot. The pain was bothering me enough to take ibuprofen.
5 weeks ago I reached up in a standing position and I couldn't bear weight on my foot due to extreme calf pain. I was unable to stand on my tippy toes. Podiatrist sent me home with 1500mg nabumetone and said to come back in 2 weeks diagnosing me with tarsal tunnel after pushing on foot with his hand to find pain points. I began physical therapy 2x a week.
Eventually I was able to walk but not without pain. The med prescribed made me tired and my belly hurt so I took ibuprofen instead. At my 2 week appt with podiatrist he offered me cortisone telling me it was more diagnostic to find out where to operate or a cam walking boot. I chose the boot - that was 3 weeks ago. Last week I took off 5 days off my part time custodian job, took the med prescribed and layed low icing and resting. Felt much improvement, but still unable to walk barefoot due to heel/pad/calf pain.
Back to my 2nd day of work wearing my boot and the calf pain is getting worse. I did get a 2nd opinion last week by an orthopedist and he acted as if I wasn't telling the truth about my pain. I am looking for help with my next podiatrist appt. I understand that sesamoid can cause other issues - I also pinched a sciatic nerve on same side of body after recent sesamoid pain. I know that cortisone will be my next option and it scares me. I am not confident about the diagnosis of tarsal tunnel. The Dr. said he could do other tests but they wouldn't tell him much.
Am I correct that if I get injected in the wrong spot that I could have other problems? I am somewhat mobile now and have no interest in making the problem worse. I understand that cortisone is a band aid to the issue and the shot itself truly freaks me out. Would you recommend an mri or any other tests to make my diagnosis more concrete? If I truly have tarsal tunnel I believe the Dr. wants to do surgery and resources online say I have a 50/50 chance of being better. The recovery of surgery seems miserable and I really don't want to be immobile. I have already given up the gym I went to 4x a week. When I spoke with orthopedist about the sesamoid/sciatice nerve issue playing a part in my current issues I got a blank look. I want to go to podiatrist armed with information to help me make the best decision for myself. Can you help me?
Regards, Toni (name changed)
Toni,
I am out of the office until 9/29 and will try to get back to you that week. Rich
Hi Dr. Blake,
I got a 3rd opinion yesterday and he thinks baxters neuritis and planters fascitis. He listened to my ideas of right side issues and I am having an emg. I believe this podiatrist will help me get to the issue of my pain. Writing to you and reading your blog has helped get my brain in order to advocate for a correct diagnosis. Thank you for being there to help me get this into words. I will follow up with you once I get emg results.
Enjoy your time out of the office
Hi Dr. Blake,
Thank you so much for your blog. It has empowered me to find a doctor who takes my pain seriously. I had an emg done and there are no nerve issues. I've been diagnosed with plantar fascitis and peroneus longus tendonitis. After reading your information on these issues it makes sense. I believe I have found the right diagnosis. I am off work for 2 weeks and now have a night splint along with the cam walker. Dr. also prescribed me a cream compound with lots of meds to help with pain and blood flow. I am also going to continue with physical therapy. Unless you feel the need to respond I'm ok with studying your blog on these issues and taking your advice. I appreciate your information so much and hopefully I will be pain free soon. Take care.
Dr Blake's response finally: Toni, thank you. I am back from the Greek Isles (someone had to go) celebrating my wife's big #__ birthday (intentionally left out number). I am so happy you found someone to listen. Tarsal Tunnel diagnosis is so difficult to make that considering injections and surgery for this needs to be very well thought out, with numerous opinions. With your history of sciatica, and the nerve hypersensitivity that can linger, you can have symptoms all along the course of the nerve leading to many mistaken diagnoses---from metatarsal pain, to arch pain, to heel pain, to ankle pain, to calf pain, to pain in back of the knee or thigh or butt. Changes in your gait, especially over supinating (or rolling to the outside of your foot), can trigger sciatica. This nerve hypersensitivity does not mean nerve damage, and that means the nerve testing (conduction or emg studies) can be negative. This severe calf pain that you had is typically only produced by nerve pain or blood clots, so if the calf pain gets bad again have a doppler ultrasound of your calf to rule out DVT (deep vein thrombosis). Your treatment right now makes sense (activity modification, protected weight bearing, and physical therapy). Eliminate all that sets off any pain. Do neural flossing from my blog for several days to see what symptoms it helps or irritates, but hopefully it is very relaxing to the sciatic nerve. When you stretch the calf, and you should 3 times a day, always keep your knee slightly bent to protect the sciatic nerve. As the pain calms down, all of the secondary symptoms should go first, with the pain from the main injury lingering. Daily keep track of what hurts (say at the end of the day) that day. You hopefully will see a pattern. The problem you face, when you have many symptoms, is that the docs and physical therapists can spend a lot of time treating secondary symptoms, and lose track of what is important to treat consistently. I sure hope this helps somewhat and thanks for all your kind words. Rich Patient Response: Dr. Blake,
Thank you so much for taking the time to help me with my issues. The neural flossing helped tremendously! The first time I did it my hip cracked every time and I knew we were onto something. After first day the throbbing in my foot/calf stopped and my hip hurt like crazy. After 4 days I was able to walk more comfortably and I only have pain in my heel when I walk barefoot. I saw a chiropractor and he found issues with my L5 and other things. Today I am returning to work! If I hadn't done the exercise I would have been strongly been considering cortisone in my foot due to being tired of the pain. I believe you helped me avoid the unneeded shot and I am grateful. I have an appointment with my podiatrist and I'm not sure I need to go. I would love to share this information with him, but not sure it's worth the office visit.
You are a good man for sharing your knowledge with the world. I will find a way to pay it forward. Thank you so much!
If you are suffering from tarsal tunnel syndrome, you really want an MRI like this. This MRI shows inflammation of all three tendons that run within the tarsal tunnel on the medial side of the ankle. This inflammation places pressure on the posterior tibial nerve that runs within the tunnel causing nerve symptoms of pain, numbness, electric shocks, etc. If you can reduce the inflammation, create a pain free environment, and calm the nerve sensitivity down, the symptoms should get better.
I found your blog and need some advice if you have a minute.
I have pretty bad lumbar back problems. MRI has shown lots of problems from L3 down to S1. I was referred to a pain doc for 3 rounds of steroid shots. She took new pictures and said it was time for me to see a surgeon.
At the same time I have numbness in my feet. Bad in the right. Swelling/pain in ankle, etc. Went to foot doc and was diagnosed with tarsal tunnel and neuroma. Have this in both feet, bad in right, left is manageable. He said my shoes were to narrow causing the neuroma and my high arches were falling causing the tarsal tunnel.
Basically, I'm a mess and in pain all the time. Lower back and ankles/feet. Hard to stand for very long.
I was googling and found "Double Crush" which links the lower back problems and the tarsal tunnel problems.
I need advice because I don't know how to proceed. I've tried everything, shoes, expensive orthotics, compression socks, stretching, exercises, chiropractic, massage, and others. I was prescribed shoes, orthotics, compression socks by foot doc. I was prescribed drugs (They want me to take Lyrica) by the neuro sergeon.
I'm frustrated and frightened because I'm just turning 50 and I concerned this is only getting worse. I don't know if I should see another foot doc or another back doc or what to do. I need my foot doc to talk to my back doc and discuss this problem together because my reading indicates they are related.
I'm also confused on the orthotics because some of my research shows, yes do them, other reading indicates they may be causing some of the problem and I need to go natural. I believe there is a connection and my alignment from my feet up to my back is out of wack and I don't know were to turn.
Any advice?
Frustrated and in Pain from San Antonio, TX
Dr Blake's response:
Thank you so very much for your email. Lower Back irritation to the nerves that go to the foot are unfortunately very common. I am a biomechanics expert. I need to see if I am dealing with a musculo-skeletal problem, or a neurological one, since the treatments may vary at times. You want to try to avoid foot surgery, if suggested for neuroma or tarsal tunnel, until the low back component has been worked on considerably. But, you still need to treat the foot locally.
Golden Rule of Foot: Treat the Low Back Nerve Component First to see what the Role in the Foot Pain. You are so right to want a team approach. Typically, this is a physiatrist, who can work with the medicine/epidural side, but knows what the podiatrist is doing, and what the neurosurgeon has to offer. You are in a nervous system overload right now. You should maximize support to the foot and low back (orthotics, foot strengthening/taping, core strengthening, back braces), and ways to minimize nervous irritability (oral meds, topical meds, warm soaks, neural flossing,etc.). I never recommend avoiding medications in this scenario, since you have to get the nervous system calmed down, and it can take a long while, getting the medications right. Definitely, the role of orthotic devices to stabilize your lower extremity, and lifts if you have a short leg, are a no-brainer to me. Find out who makes the best orthotics in your area. Have your doc prescribe a Standing AP Pelvic Xray to document the leg length difference standing (I have some posts in my blog on this). Treatment of a short leg is Back Pain 101 to me. Most definitely recommend surgery for the back if the nerve injury is causing weakness in your legs, but waiting a month or two to get orthotics that make your feet function symmetrically and lifts for any short leg make help considerably. I sure hope this helps somewhat. Rich
I have been dealing with sharp/shooting pain and tingling in my foot since January (I was originally diagnosed and treated for stress reactions in the metatarsals, then sesamoiditis, and for the past few months, tarsal tunnel.) The tarsal tunnel syndrome was confirmed with a NCV/EMG test, however, despite 3 months of physical therapy, surgical shoe bracing, and a 200mg daily dose of Lyrica, the pain, tingling, and numbness in my foot and ankle have grown worse. I had a recent MRI (I attached some images.). Do you see anything abnormal which could be contributing to the problem? I am about to get a second opinion for surgery. Do you have any other suggestions?
Thank you, Cindy (name changed) Dr Blake's response (after the patient sent FedEx the CD with images and reports):
Hey Cindy, I am so sorry about your situation. Hopefully, you can get this resolved without surgery. From what I gather from looking at your MRIs and reports, you injured the tibial sesamoid under the big toe joint 10 months plus ago. This caused swelling in the big toe joint, and this still exists to be worked on, since it can continue to be a trigger for nerve pain. I think the big toe joint injury still has a little healing to go, and you must daily try to protect with dancer's pads/orthotics, reduce the inflammation, and allow weight bearing since you are showing signs of some demineralization in that area. Make sure your Calcium and Vit D3 are good--typically 1500 mg calcium and 1000 units Vit D3 daily.
The nerve pain can be from many sources and normally is a combination of things. The tendon that goes under the big toe joint was still inflamed back in the ankle and probably has caused pressure on the tarsal tunnel nerves. Any limping that causes you to supinate (walk on the outside of your foot) can also be an irritant to the tarsal tunnel. You have some low back dysfunction, even if mild, but can still cause some hypersensitivity to the nervous system. L5 nerve root affects many nerves under the middle of your foot. The removable boot, even if you use an EvenUp (hopefully you did!!) can tweak the low back or hyper-extend the knee causing neural tension.
All this being said, you have many reasons, non-serious that could have (and still are) stirred up your nervous system. You have had all the right tests, but now you need to find someone to calm down your nervous system. Addressing the possible triggers are important, so decreasing inflammation in the big toe joint makes sense, making sure you are not walking to the outside of your foot, making sure you are not hyper-extending your knee, making sure your gait is centered (not dominant to one side which is always bad from the spine), and perfecting all the ways to calm down the nervous hypersensitivity. I have many posts on my blog that can help you, but you need someone in pain management that can help with Rxs,etc. Medicine seems good at evaluating and treating damaged nerves, not hypersensitive nerves.
To help you get started, work daily icing and contrast bathing for the big toe joint. Weight bear to tolerance if possible gradually improving duration. See a physical therapist to find out how to protect the sciatic nerve, and keep your spine neutral when you do activities, and outline a plan to increase activities. You might need an epidural injection to calm down the nervous system, and if you have any sympathetic signs (skin discoloration, changes in sweating, etc), also need a sympathetic block. I had to have both after a back injury, but they were done at the same time. Treatment to the foot/ankle has to be gentle due to the nerve hypersensitivity without injections (unless you are calmed down). Deep massage should also be avoided. You need to be doing non painful strengthening of your foot, and typically swimming or stationary bike are used for cardio (this is where the physical therapist can help). Hypersensitive nerves love gentle motion, heat, gentle massage. Learn what is neural flossing so that someone can show you if appropriate. Easy to do multiple times a day.
In terms of medicine, stay on 200 mg Lyrica right now, and add Cymbalta or Elavil at bedtime. These changes are common to begin to get ahead of the symptoms and necessary since you are increasing in symptoms. Have a RX for Lidoderm patches and a compounding medication for nerve pain (you could start using the OTC Neuro-Eze and find where you can massage without increasing pain). I have patients who can not massage due to the pain, but a compounding spray is given which helps.
There are 2 types of physical therapy--musculo-skeletal and neurological. You need neuro based physical therapy right now. There is a daily, sometimes hourly, distinction to be learned about Honoring your Pain vs Working Through your Pain. It is an important skill to learn.
Cindy, I hope this helps you somewhat. Keep me in the loop. Rich
When patients experience foot and ankle nerve pain, a possible diagnosis of tarsal tunnel syndrome is suspected. Below are some MRI images noting swelling internally that could produce enough pressure on the posterior tibial nerve (marked with an arrow). In this case, an anti-inflammatory approach to reduce the swelling may significantly reduce the pressure on the nerve, easing the symptoms of nerve pain. However, in the long run, finding the cause of this inflammation will be important. The inflammatory reaction not only involves the ankle joint, but also the 3 tendons in the area (PT, FHL, and FDL) and may be a sign of an inflammatory disorder. Nerve pain, when constant and severe enough, can produce swelling, and the swelling lead to more pressure on the nerve, thus even more nerve pain. In this case, Nerve Pain Begets Nerve Pain and has a life of its own. Finding the source of the original nerve pain will be crucial to helping in the long term.
The marked Posterior Tibial Nerve is a branch of the Sciatic Nerve as it comes off your back, through the sciatic notch, behind the hamstrings and knee, down the back of the leg, and into the medial side of the ankle (Tarsal Tunnel area) below the inside ankle bone (medial malleolus).
Arrow marking the posterior tibial nerve quite exposed to external pressures and being pressured by internal swelling.
Swelling within the Tarsal Tunnel with the arrow pointing approximately where the nerve would lie.
